Provider Demographics
NPI:1033287248
Name:UROLOGIC CONSULTANTS OF SOUTHEASTERN PENNSYLVANIA LLP
Entity Type:Organization
Organization Name:UROLOGIC CONSULTANTS OF SOUTHEASTERN PENNSYLVANIA LLP
Other - Org Name:UROLOGIC CONSULTANTS OF SE PA LLP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-667-3020
Mailing Address - Street 1:1 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1017
Mailing Address - Country:US
Mailing Address - Phone:610-667-3020
Mailing Address - Fax:610-667-1817
Practice Address - Street 1:1 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1017
Practice Address - Country:US
Practice Address - Phone:610-667-3020
Practice Address - Fax:610-667-1817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207ZP0102X, 2085R0001X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018621670001Medicaid
PA110709Medicare PIN